A population health management approach starts from the perspective of understanding people, their lives and the impact of the disease processes on them, rather than treating episodes of illness and then designing and delivering pathways of care that support them

In practice this requires diverse professional teams to share decision-making and accountability across specific pathways of care and outcomes for patients in order to eliminate fragmentation of care.

To support the approach information and data systems are required to create greater understanding of the needs of different segments of the population and to support evaluation across the whole pathway/system including the ability to allow information, both clinical and administrative, to flow around the system in as close to real time as possible, through an integrated digital record

A Population Health Management Tool is used to segment the population to understand how different population segments have different needs to meet as seen in the graph below used for building insights.